Effect of carotid endarterectomy on brain damage markers.

OBJECTIVES: Carotid endarterectomy (CEA) is a recommended treatment in the prevention of ischemic stroke. However, this procedure may cause neurological complications caused by cerebrovascular damage. While YKL-40 is a proinflammatory protein, neurofilament light polypeptide (NEFL) and brain lipid-binding protein (FABP7) are structural components of the brain. The aim of the study was to investigate YKL-40, NEFL, and FABP7 in the serum of patients undergoing CEA. MATERIALS AND METHODS: The study included 25 participants who underwent CEA due to internal carotid artery stenosis. Blood samples were taken from each patient at three different intervals: prior to the surgery, 12 h after the surgery, and 48 h after the surgery. Serum levels of these brain damage markers were measured by enzyme-linked immunosorbent assay (ELISA). RESULTS: The study showed that the serum YKL-40 level was significantly increased 48 h after CEA when compared to the level prior to surgery and also when compared to levels 12 h after surgery. There were no statistically significant differences in serum NEFL and FABP7 levels between all three recorded measurements. CONCLUSIONS: Data from our study showed that CEA affects serum YKL-40 but not NEFL and FABP7 levels. This implicates that YKL-40 may be a valuable serum marker of brain damage after CEA. However, the observed change in serum YKL-40 level in patients after CEA does not necessarily warrant a change in recommendations concerning the use of this treatment in patients with high-grade internal carotid artery stenosis.

Are the vasodilators needed in critical limb ischemia? Laser Doppler flowmetry study.

Twenty patients with critical limb ischemia, fulfilling the criteria of European Consensus of Critical Limb Ischemia, were included in the study. Fifteen healthy subjects served as the controls. Laser Doppler flowmetry method was applied to assess the peripheral skin microcirculation during provocation tests such as transcutaneous electrical nerve stimulation and veno-arterial reflex. In physiological conditions transcutaneous electrical nerve stimulation evokes short term, reversible increase of cutaneous blood flow during stimulation. Veno-arterial reflex is defined as an increase of precapillary resistance while standing or lowering of the extremity, mirrored by the reduction of skin perfusion. The results of the study justify the thesis, that the vasodilators may not be effective in the treatment of critical limb ischemia. Further trials directly assessing the influence of vasodilatating agents on microcirculation in critical limb ischemia are required.

Injury in vascular surgery--the intimal hyperplastic response.

Intimal hyperplasia is extensively studied in order to improve arterial reconstruction outcome. The mechanisms leading to stenosis or restenosis may vary according to the technique used for arterial reconstruction. Lesions are mostly made of an accumulation of smooth muscle cells and fibroblasts, with only sparse inflammatory cells. The accumulated material reduces the graft lumen and ultimately induces thrombosis. Intimal hyperplasia with smooth muscle cell and matrix accumulation is the prominent feature in all these situations with evidences of intense cell proliferation and cell death. The purpose of this review is to present the biology of intimal hyperplastic response based on the recently published data. Experiments in the rabbits have shown that the vein wall thickening is mainly regulated by the tangential wall stress which is applied transversely to the vein wall as a blood pressure. Experiments in the rat carotid artery balloon injury suggested that heparin could be used as a treatment to prevent intimal hyperplasia. Treatments for preventing restenosis after angioplasty or stenoses development in bypasses have been disappointing clinical evaluation suffers from insufficient prospective randomized studies. Intimal hyperplasia is the major cause of failure after arterial reconstruction. The biology of intimal hyperplasia is complex, and treatment disappointing. Some types of hyperplasia may need to be preserved in order to prevent functional atrophy and aneurysmal dilatation of vein grafts.

Possibilities of spatial imaging of carotid arteries pathologies in Power-Doppler US.

The aim of the study was to assess the value of Power-Doppler US spatial reconstructions in examining pathologies of carotid arteries for determining its role in the diagnostic algorithm. 3D Power-Doppler US reconstructions were performed in 19 patients with pathologies of carotid arteries qualified for surgical treatment on the basis of Color-Doppler examinations. Digital data of 2D US sections secondarily gave spatial pictures. Most frequently, 14 times, different degrees of carotid artery stenosis were found, in 3 cases critical, and complete impatency was observed twice. The narrowings were caused by both atheromas and parietal clots. In 3 cases the internal carotid artery formed an angular refraction. Spatial pictures also determined the geometry of division of common carotid arteries. It was found that Power-Doppler 3D US perspectively visualizes the configuration of carotid vessels and the range of their pathology facilitating understanding of the extent of changes and mutual topographic relationships. Spatial imaging let visualize atheromas and ulcerations of their surfaces besides the degree of carotid arteries narrowing.

Mid-term results of endovascular versus open repair for abdominal aortic aneurysm in patients anatomically suitable for endovascular repair.

OBJECTIVES: to prospectively evaluate the mid-term results of endovascular and open repair in patients with abdominal aortic aneurysm (AAA) anatomically suitable for endovascular repair. MATERIAL AND METHODS: between January 1995 and March 1999, among 438 patients treated for AAA, 180 (41%) were suitable for endovascular repair as assessed by computed tomography (CT) scan and angiogram. Seventy-three were treated by various commercially available endovascular grafts (EV) and 107 by open repair (OR). Postoperatively, patients were followed every 6 months with clinical examination, duplex scan and in the EV group, CT scans. Patients>> demographic data, intra- and postoperative events were recorded prospectively in a computerised database and compared for each group. RESULTS: median age, sex ratio, preoperative risk factors and aneurysm diameters were not statistically different between the two groups. Respectively in the EV and OR, the average duration of operation was 149+/-73 mn, and 133+/-44 mn (NS), blood loss 96 ml+/-28 and 985 ml+/-113 (p<0.01), duration of hospitalisation 7 days+/-2 and 13 days+/-7 (p<0.01). The one-month mortality was 2.7% (n=2) for EV and 2.8% (n=3) for OR. The rate of cardiac and pulmonary complications was significantly higher in the OR group (6. 9% versus 19.6%, p=0.017). At a mean follow-up of 1 year, the cumulative survival rate was 82.2%+/-7.5 for EV and 96%+/-2.12 for OR (log-rank test p=0.043). No patients died of rupture, but three patients had to be converted to open surgery. Twenty-two percent (n=16) patients in the EV and 7.5% (n=8) in the OR were submitted to a subsequent minor or major reintervention (p=0.007). At 1 year, the cumulative rates free of any reintervention were respectively 78. 8%+/-6.7% and 92.9%+/-2.7% (p=0.001). In the EV there were 17 early endoleaks (23.3%). At the end of patient's follow-up seven endoleaks (9.6%) persisted. The primary success rate defined by the absence of endoleak and the absence of reintervention was 54 (74%) with EV and 101 (94%) with OR (p=0.001). CONCLUSION: EV is a promising technique. However, with current devices and indications the immediate benefits, mainly less blood loss, fewer cardiac and pulmonary complications, and shorter hospitalisation time, are outweighed by a higher rate of reinterventions to treat endoleak, or to maintain patency of the graft.

Percutaneous stenting of an latrogenic superior mesenteric artery dissection complicating suprarenal aortic aneurysm repair.

PURPOSE: To report endovascular repair of an iatrogenic superior mesenteric artery (SMA) dissection caused by a balloon occlusion catheter. CASE REPORT: A 68-year-old man with a suprarenal aortic aneurysm underwent conventional prosthetic replacement, during which visceral artery back bleeding was controlled with balloon occlusion catheters. Six hours postoperatively, the patient experienced an episode of bloody diarrhea with abdominal pain and tenderness and mild metabolic acidosis. Colonoscopy revealed colitis (grade I) without necrosis of the right and left colon. An emergent abdominal computed tomographic scan showed signs of mesenteric ischemia with bowel dilatation and SMA wall hematoma; angiography identified a dissection 1 cm distal to the SMA origin. An Easy Wallstent was deployed percutaneously, successfully reestablishing SMA patency. The postoperative course was uneventful, and the patient remains asymptomatic with a patent SMA stent and aortic graft at 1 year. CONCLUSIONS: latrogenic SMA dissection should be suspected after suprarenal aortic aneurysm repair if signs of mesenteric ischemia arise. Prompt and thorough imaging studies are necessary to confirm the diagnosis and assess the potential for an endoluminal treatment.

[Carotid angioplastic: what future?]. / Angioplastie carotidienne: quel futur?

ADVANTAGES AND RISKS: Widely advocated as reliable and cost-effective, carotid angioplasty offers many advantages. Theoretically, general anesthesia can be avoided and no incision is required, authorizing its indication in patients with a contraindication for conventional open surgery although the risks of vascular complications--emboli, dissection, acute thrombosis--and general complications must not be underestimated. NEED FOR VALID ASSESSMENT: Few studies evaluating this new technique have been published. Among the open trials including over 100 patients, indications have generally been limited to patients with a high surgical risk and combined morbidity and mortality has been reported to vary from 2.8% to 9.6%. No rigorously controlled comparison with conventional surgery has been published although several projects are currently under way or in the planning stages (CAST in Europe and CASET and CREST in North America). LESSONS FROM THE CURRENT SITUATION: Carotid angioplasty requires a highly equipped facility and a multidisciplinary team with competence in catheterization and micro-catheterization, thrombolysis, and stenting techniques. Technical advances in material engineering are also needed to provide flexible, stable and modulable stents. Despite the still imprecise nature of the current situation, one can predict that these techniques will come to be complementary, if not competitive, alternatives to conventional carotid surgery.

Pulsating mass after accidental artery trauma: diagnosis with duplex ultrasound and the role of angiography.

BACKGROUND: Pulsating mass located close to peripheral arteries is usually considered as a result of arterial wall injury. Clinically important is to distinct pseudoaneurysm from haematoma and also to evaluate proximal and distal arterial bed for the assessment of the injury extent. A few previous reports claim good results of duplex Doppler US diagnosis of iatrogenic (post-catheterization) femoral artery injuries. This paper presents diagnostic findings of arterial injuries caused by accidental trauma. PATIENTS AND METHODS: A retrospective analysis of 49 patients with post-traumatic pulsating mass close to peripheral artery was performed. The diagnostic results of both sonography and angiography were reviewed. All the patients underwent B-mode and duplex Doppler US examination using PW-, color- and power Doppler imaging techniques. RESULTS: 34 pseudoaneurysms were diagnosed correctly with typical B-mode, color/power Doppler images and PW-Doppler spectral waveforms. The lack of flow signal and distinctive B-mode images enabled proper diagnosis of 13 haematomas. In 2 patients duplex Doppler US misdiagnosis occurred, because of secondary pseudoaneurysm formation, primary diagnosed as haematoma. The 47 correct US findings gave 96% efficacy in distinguishing pseudoaneurysm from haematoma, which compares well with the other studies. In 20 patients suffering from peripheral ischemia, US examination, in spite of proper distinction between pseudoaneurysm and haematoma was unable for precise estimation of proximal and distal arterial damage. Thus, it was successfully supported with angiography before surgical decision making. Angiography was also necessary in 8 patients with severe injuries of carotid, subclavian and palmar arch arteries, hardly accessible for ultrasound penetration. CONCLUSIONS: We conclude that duplex Doppler US is essential for noninvasive, unequivocal distinction between pseudoaneurysm and haematoma but it could not completely replace contrast angiography in the evaluation of post-traumatic pulsating mass caused by severe, extensive trauma, frequently complicated with peripheral ischemia or located in regions with poor access for ultrasound penetration.